“Ultrasound-assisted digital photo diagramming of problem fistulas”
After an arteriovenous fistula is created, it must “mature“, and when it is judged mature it is released for use. For many patients, this begins a difficult period in which the dialysis personnel “learn” the fistula. During this process, the patient may experience infiltration, difficult cannulation and frustration. After a number of difficult cannulations it is not uncommon for the dialysis personnel to fall back onto reliance on the catheter, or to tell the patient “This fistula is no good”. Failure to successfully use the fistula means that the patient remains at elevated risk from a catheter that cannot be removed.
Long ago, a patient was sent back to me with the complaint that his fistula was unusable. An ultrasound and fistulogram showed that there were places in the fistula that could be cannulated, if only you knew where to put the needles. I took a picture of the patient’s arm, sketched the fistula with directions, and the ultrasound assisted digital photo diagram was born.
Since that first case in 2003, we have usually offered the patient the ultimate guide to cannulation. A picture of the arm is printed, then the fistula drawn on the printed photo with the assistance of an ultrasound examination. The course of the fistula is indicated, the size at various points, the depth below the skin at various points, location of branches, suggested areas for cannulation, and suggested areas to avoid. Copies of the photo-diagram are given to the patient for the unit.
The ultrasound-assisted digital photo diagram does not solve all problems. Some fistulas are too deep, some require operative or endovascular intervention, some will never be big enough to cannulate, and some fistulas have insufficient flow. But, frequently, a fistula can be converted from a frustrating problem to a reliable asset, reducing complications, and allowing the catheter to be removed earlier.
A survey of dialysis units confirmed that these diagrams are of value, and considered useful. Unfortunately, these diagrams are not billable, and as unsupported “extras”, are almost never done by most surgical offices. We at Michigan Vascular Access, PC continue to provide this service, because we know it helps patients, and are committed to lobbying Medicare through MiDRE to recognize the value of these services. Your support will allow us to continue providing these services to individual patients, and to promote beneficial changes for all.